Advertisement

How Does Gender-Affirming Voice Therapy Work?

Here are answers to your top questions about what to expect from the process, plus how to find knowledgeable providers.

Medically reviewed in August 2021

For many transgender, gender nonconforming and nonbinary people, changing your voice—whether through medical intervention, vocal training or both—is a key part of the gender-affirmation experience.

The process can look different for everyone, depending on your goals and preferences. Many gender-diverse people, in fact, will choose not to pursue voice therapy. If you do wish to change your voice, there are experts and resources available to help you understand your options and guide your care.

What providers might I seek for voice therapy?
You may try to change the sound of your voice on your own. It’s important to realize, though, that doing so without professional help could lead to vocal fatigue, strain or discomfort over time as you stress the muscles around your vocal cords (also known as vocal folds). If you have access to the appropriate providers, there are a variety of specialists who can help you achieve your goals.

You might work with a vocal coach, a singing or theater teacher, or a medical doctor such as a laryngologist. Speech-language pathologists (SLPs) are often the go-to providers, as they are specially trained to address overall vocal health, as well as behavioral changes related to voice and communication. Look for an SLP with experience working with gender-diverse people who also understands the various dimensions of gender-diverse physical and mental health.

“By finding a certified SLP, designated by ‘CCC-SLP’ after their name, you can be sure that you are being taught evidence-based, effective and safe strategies by a licensed professional who can help assist you in your vocal transition while ensuring you aren’t straining or hurting your voice,” says Jessica Schwartz, MS, CCC-SLP, a speech-language pathologist and owner of Resonate Voice and Speech Services in Philadelphia, specializing in gender-affirming voice therapy. (The CCC indicates a certificate of clinical competence in the field.)

What are the main approaches to voice training?
Depending on your gender-affirmation goals, you may pursue masculinizing, feminizing or androgynous voice therapy.

Voice feminization: If you’re taking feminizing gender-affirming hormone therapy (GAHT), you shouldn’t expect to experience substantial changes to your voice as a result. The estrogen typically used in feminizing GAHT does not affect vocal quality. Vocal training (with surgery, if needed) is thus the primary approach to feminizing one’s voice.

The aspects of your voice that an SLP will typically address over a course of therapy include:

  • Pitch (how high or low your voice sounds)
  • Pitch range, or intonation (how much of a change in pitch you exhibit during normal speech)
  • Vocal resonance (the location from which your voice predominantly vibrates, such as the chest, throat, lips or nose, and how you shape the sound of your voice in those spaces)
  • Prosody (the melody of your speech, which involves changes in loudness, pitch and the stress placed on certain words)
  • Articulation and speech rate (how clearly you say each word and how quickly or slowly you speak)
  • Non-verbal communication, such as facial expressions, eye contact and posture

Each of these factors can play a role in how you and others perceive your voice. Generally speaking, voices considered conventionally feminine have higher pitch and greater variability in pitch, while conventionally masculine voices are associated with lower pitch and greater use of stress or loudness.

Voice masculinization: If you’re taking masculinizing hormone therapy (testosterone), you might find that the thickening of your vocal cords that results from the hormones lowers the pitch of your voice to a level that meets your goals.

About 90 percent of transgender men are satisfied with their voice changes after four to five months on testosterone therapy, according to a 2013 study published in The Laryngoscope. If you feel you would also benefit from vocal training, an SLP experienced in working with transmasculine clients can help you adjust additional aspects of your voice, such as your breathing, resonance and speaking patterns, as well as any other elements you’re unsatisfied with.

Androgynous vocal training: You may desire a voice that is neither conventionally masculine nor feminine. This is typically achieved using masculinization and/or feminization voice strategies shaped and guided by your goals. The approach may also focus on achieving communication characteristics perceived as gender-neutral, such as an average speaking pitch range.

Schwartz notes that while most clinicians who specialize in this area are familiar with voice training across the gender spectrum, it may be beneficial to speak to potential providers about their comfort level and experience with androgynous vocal training before beginning therapy.

Insurance coverage for voice therapy differs across insurers, so check with your provider before beginning therapy to find out how much, if any, of your therapy will be covered.

What can I expect at my first voice training appointment?
Intake appointments typically involve a four-stage assessment to enable your SLP to understand your situation and how best to work with you. (Depending on the healthcare practice, a laryngologist may also be involved in an initial examination.)

Step 1: Oral-Motor Examination: The SLP will examine your face, mouth and throat muscles to check for weaknesses or coordination problems. Most people will have no issues here, but it is important that your SLP knows about anything that could affect your training before you begin.

Step 2: Voice Evaluation: The SLP will test the current state of your voice, including your pitch, pitch range, resonance, articulation, intonation and breathing.

Step 3: Communication Skills Assessment: The SLP will assess your current verbal and non-verbal speech behaviors during conversation. This can help you pinpoint the areas you’d like to change.

Step 4: Identification of Goals: This is a conversation that helps the SLP determine what training elements you will need. A good SLP will take the time to understand what you want, create a plan that can get you there safely and ensure that they stay true to your goals along the way.

You’ll typically set up a schedule of regular visits with your SLP. Voice therapy, particularly feminizing voice training, usually entails weekly sessions with an SLP over months or even years, depending on your goals and circumstances.

“It’s important to recognize that changing your voice is a process, and that it doesn’t happen overnight,” says Schwartz. “It takes time, practice, motivation and mindset to make lasting behavioral changes.”

What about surgical options?
While the primary approach to changing your voice is typically voice therapy, surgery is also an option if therapy alone does not yield desired results. Surgeries for voice feminization tend to focus on raising pitch by making adjustments to the size, length or tension of the vocal cords. Surgeries for voice masculinization are less common, and typically involve relaxing the vocal cords.

Feminizing laryngoplasty, for example, although rare, is becoming more popular as an alternative to feminizing voice training. This is appealing for some, because it can result in a bigger change in pitch and doesn’t require months of training or practice.

As with any surgery, there are risks to consider, such as the chance of permanent damage to your vocal cords. It can also be expensive, ranging from $5,000 to $10,000. Unfortunately, health insurance plans rarely view this surgery as “medically necessary,” so few will provide coverage for it. It’s also important to recognize that because voice feminization surgery will only change your pitch, it’s likely you will still need to work with an SLP on adjusting other vocal behaviors, such as intonation, prosody and articulation.

If you’d like to pursue the surgical option, speak with your SLP about the potential benefits and risks.

Resources to explore
The best way to start on a course of voice therapy is to get a recommendation for an SLP from a knowledgeable and trusted primary care provider. If you need additional help identifying experienced and affirming voice providers, there are several online resources that can help:

Medically reviewed in July 2021.

Sources:

Harvard Medicine. The Sounds of One’s Own Voice. Spring 2021.
Journal of Voice. “My Voice Is My Identity”: The Role of Voice for Trans Women’s Participation in Sport. July 25, 2018.
Journal of Craniofacial Surgery. The Role of Voice Therapy and Phonosurgery in Transgender Vocal Feminization. July/August 2019.
The Guardian. What does a woman sound like? Vocal training helps trans women find their voices. May 20, 2019.
UCSF Transgender Care, Department of Family and Community Medicine, University of California San Francisco. Transgender voice and communication – vocal health and considerations. Guidelines for the Primary and Gender-Affirming Care of Transgender and Gender Nonbinary People; 2nd edition. Deutsch MB, ed. June 2016
Your Lessons Now. Androgynous Voice. Accessed July 30, 2021.
Speech Pathology Master’s Programs. Finding a Voice: A Guide to Gender Affirming Voice and Communication Training. 2021.
Mayo Clinic. Voice feminizing therapy and surgery. 2021.
DeVore EK, Gadkaree SK, Richburg K, et al. Coverage for Gender-Affirming Voice Surgery and Therapy for Transgender Individuals. Laryngoscope. Published online August 10, 2020.
Nolan IT, Morrison SD, Arowojolu O, et al. The role of voice therapy and phonosurgery in transgender vocal feminization. J Craniofac Surg. 2019;30(5):1368-1375.

Featured Content

article

What Transgender Men and Transmasculine People Need to Know About Gynecologic Cancers

Screening is usually based on your anatomy—not your gender—but there are a few caveats to keep in mind.
article

What Transgender Women and Transfeminine People Should Know About Prostate and Testicular Cancer

Your history of gender-affirming hormone therapy and surgery may impact your risk.
article

Insurance Coverage for Gender-Affirming Health Care: A Troubleshooting Guide

Here's how to know what your insurance covers and what to do if your services are denied.
article

What You Need to Know About Feminizing Hormone Therapy

Understand the benefits of gender-affirming hormone therapy, as well as what to expect when you begin taking it.
article

Fertility Care and Family Planning for Transgender and Gender-Diverse People

Here’s how to understand your options and find safe, affirming care.